The growing evidence supporting the promise of new HIV prevention products, like microbicides, requires that groups start planning now for how best to roll-out prevention interventions in the future, U.S. Global AIDS Coordinator Eric Goosby and Special Advisor on Health Policy to the Director of the White House Office of Management and Budget Ezekiel Emanuel said Monday during a USAID Microbicide Stakeholders Meeting in Washington.

The pair participated in a discussion moderated by USAID's Robert Clay as part of a day-long event organized by the agency for global health and policy leaders to review microbicide development progress and map out the steps needed make the products available in developing countries.

"I think this is a remarkable moment in our belief that our [prevention] toolkit is being added to and expanded in a way that will really enhance the ability for women, men who have sex with men, hopefully injection drug users and sex workers ... who are participating and will continue to participate in high-risk behaviors, to have an option to modulate that risk," Goosby said.

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"There are now 33 countries on our planet that have greater than 25 percent reduction in new cases [of HIV/AIDS]. Twenty-two of those countries are in sub-Saharan Africa," Goosby said, pointing to the recent UNAIDS annual report. "Seeing these numbers is a reflection of what we hope combination prevention approaches will continue to show us and enhance," he added.

Still, tensions remain over the amount of resources directed to HIV treatment versus prevention, as well as how best to deploy prevention interventions and measure synergy between multiple prevention approaches, Goosby noted.

Emanuel, who recently returned from a three-nation tour in Africa, noted the overlap between the aim of HIV prevention strategies to reach individuals at different points in the health system and the Global Health Initiative's (GHI) focus on the integration of health services to maximize resources and interventions. "You need to integrate these prevention strategies not with the HIV-positive community primarily, but with the HIV-negative and the people who are accessing the health care system for all sorts of other reasons," Emanuel said. "This is one of the reasons we put integration into the Global Health Initiative and one of the reasons PEPFAR is a critical platform for the Global Health Initiative."

While PEPFAR has demonstrated success at scaling up treatment for patients living with HIV/AIDS around the world, "we have to do the same thing for combination prevention," Emanuel said. Goosby, noting the role PEPFAR sites could play in the roll-out of prevention products, said, "These sites are already seeing women" who could be candidates for microbicides.

Even so, the cost associated with "deployment and operations is the place where the challenge is," Emanuel said. "This issue of impact, of bang-for-the-buck, is vitally important," he said.

CAPRISA "revived a whole field that many of us believed would be an important prevention strategy but had [experienced] repeated failures," Emanuel said. "I think this kind of meeting suggests we're all optimistic [about the promise of microbicides] ... and the real issue is to be sure that when we do get those data and understand them that we're ready to roll this out and we don't have years and years of delay before we have this effectively out there. Obviously there are many hurdles with this kind of intervention ... but I think starting now is absolutely essential," he said.

The USAID meeting also featured a series of discussions examining such topics as advancing HIV prevention for women, moving forward on Tenofovir gel licensure and possible lessons to be learned from other efforts that could help lay the groundwork for introducing a microbicide product into the developing world (Jennifer Evans, Kaiser Daily Global Health Policy Report, 11/30).

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